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SAN J U AQ U I N I-nvironinental Health Depailment TEMPORARY FOOD VENDOR'S APPLICATION All food vendors(both for profit and non-profit)are required to return a signed and completed copy of this checklist to the festival coordinator three(3)weeks prior to this event. i. 1.Name of Event: Lodi Stretlyf, Date(s): 0-)- 03-2.020 2. The following is information about my organ izationlbusiness: Name of organizationlbusiness: (htl ha v r� roctUC{S Address. by OMbS f2 L( erred CA g5341 Phone: ( 2 oq ) foq 3 - '0 02-B Alternate: ( 2 C;q 6 3 - 3 810 3. List food to be sold or given to the public: eel gee, U er¢oo granola- lil<< e-n4 o e 4 1 am providing food that is NOT prepared at home: ❑Yes Evf No All food is prepared on-site or is from approved commercial facilities: [71 Yes ❑No Name of facility 04t1 WX Ro r-Lr `s Phone: 2- 03 ~B0213 Address of facility: t6gf 5 - Cort)j2s Rd. "erC ed tA cf 53 L{ 5. 1 am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, dust and the public) ❑ A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly screening, completely enclosing open food areas. It will also have a smooth and cleanable floor (concrete, asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation areas from the public. ❑'Other(specify):. W -foot.! is p►'P- n GtL W Qr d Note: The only operations not required to provide enclosed booths are those which sell beverages from approved dispensers, or prepackaged foods from approved sources. 6. Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: ❑Approved bottled water. ❑ On-site hose bib that is connected to a potable water source. [Other(specify): tJ t It 7. Electricity is provided for my booth's use: ❑Yes F1 No 8. 1 am providing an accurate probe thermometer to�asure the hot and cold holding of potentially hazardous foods during all times of booth operation: ❑Yes No 9. 1 am providing [tie following hot temperature control for the hot holding of all potentially hazardous foods above 135`F: 0 Camp stove ❑Sterno&hotel trays ❑ Double steamer ❑Steam table&lids N ❑Electric stove top ❑Other(specify) Note: Examples of potentially hazardous food Include: meats, tarnales, cooked beans, rice, vegetables, potato salad,eggs, and dairy products. 1868 t_ Ifazelton Avenue F 91ockton, California 952051 T 209 468-3420 1 F 209 464-0136 f www.slgov-ofglwhd fru It,02Page 7 of 11 TEA1P EVENT APP OW OU26